*Required Field
*First Name:   *Address:  
Middle Initial: *City:  
*Last Name:   *State/Province:  
*Date Of Birth:   *Zip or Postal Code:  
*Social Security (Last 4 Digits):   *Home Phone:  
Marital Status: *Email:  
Cell Phone:

Patient Employer Information

Place Of Employment: Referred by:
Work Address: Occupation:
Work City: Work State/Zip Code:
Work Phone:
Type Of Employment:

Patient Partner Information

Driver's license?: First Name:
Driver's License Number: Middle Initial:
State Of Issue: Last Name:
Passport Number: Date Of Birth:

Insurance Information of Insured

Social Security:
Name: Home Phone:
Middle Initial: Cell Phone:
Last Name: Relationship:
Insurance Name: Additional Information:
Insurance Address: Occupation Of Insured:
Insurance City: Employer Name:
Insurance State/Zip: Employer Address:
Insurance Country: Employer City:
Insurance ID#: Employer State/Zip:
Insurance Group: Work Phone:
Insurance Phone: Email:

Primary Care Physician Information

Primary First Name: Primary Care Address:
Primary Last Name: Primary City:
Primary Phone: Primary State/Zip:
Primary Fax: Primary Country:

Emergency Contact Information

Contact First Name: Contact Address:
Contact Middle Initial: Contact City:
Contact Last Name: Contact State/Zip:
Contact Phone: Relationship:
Contact Cell: Contact Email:

Medical History

Have you ever been treated for:

Heart Disease High Blood Pressure Cholesterol Disorders Blood Clots
Thyroid Disease Anesthetic Complications Infertility Diabetes
Asthma Tuberculosis Lung Disorders Abnormal PAP Smear
Hepatitis or Liver Disorders Kidney Stones Kidney Disease Seizures
Migraine Headaches Neurological Disorders Psychiatric Disorders Cancer
Birth Defects or Inherited Disorders History of Blood Transfusion Anemia or Blood Disorders Stomach or Bowel Disorders
Other Medical Issues
If yes indicated for any, please describe:

Hospitalizations and Operations

Please list any surgeries you have had, what year they took place, and any complications from surgery or problems with anesthesia:
Please list all the current medications and dosages:
Please list all allergies:
Do you smoke? If yes, how many per day?
Do you drink? If yes, how many per day?
Do you use drugs? If yes, which ones?
Date of your last PAP? Was it abnormal ?
First day of last menstrual period? Was it abnormal?
List any problem with irregular periods:
List any problem with painful periods:
How many times have you been pregnant?
How many children are still living?
Number of full term babies?
Number of premature babies?
Abortions? Miscarriages?
Have you had any ectopic (Tubal pregnancy) pregnancies?

Genetics Screening

Do any of the following apply to your family or to your partner's family? If yes, please specify which family member.

Mediterranean (Italian, Greek) or Asian background If yes, what relation?
Ashkenazi Jewish Background If yes, what relation?
Neural tube defects (spina bifida, anencephaly) If yes, what relation?
Sickle Cell Disease or Sickle Cell Trait If yes, what relation?
Huntington's Chorea If yes, what relation?
Birth Defects If yes, what relation?
Down Syndrome If yes, what relation?
Hemophilia or Other Bleeding Disorders If yes, what relation?
Muscular Dystrophy If yes, what relation?
Cystic Fibrosis If yes, what relation?
Intellectual Disability If yes, what relation?
Other Hereditary Diseases If yes, what relation?

Family History

Does anyone in your immediate family have any of these conditions?

Breast Cancer If yes, what relation?
Ovarian Cancer If yes, what relation?
Colon Cancer If yes, what relation?
Diabetes If yes, what relation?
Heart Attack If yes, what relation?
Thyroid Disease If yes, what relation?
Osteoporosis If yes, what relation?

 

Fee Policies for Patients

BocaFertility will bill your insurance for coverage charges incurred in our office. Your deductible and co-payment are due at the time of your visit.

Some services provided by our office may be non-covered. If we have been informed that the services is not covered, you will be responsible for payment in full at the time of the visit. Otherwise, we will file a claim and bill you if its denied. You will be held responsible for any charges not paid by the insurance company, regardless of the reason. Payment is due in full by the 30th of the month in which statement is sent. We accept cash, check, American Express, MasterCard, Visa, or Discover. We also offer our patients the option of applying for credit with a medical finance company. If you will be paying cash, please note that we do not keep change in our office. (If you do not have the exact amount, we can credit your account for the overpayment or mail you a check.)

A $30 charge is applied to any check returned by the bank. Past due accounts are assessed a 1% monthly late charge. Accounts sent to an outside collection agency are responsible for all legal fees and collection costs. If your insurance coverage is terminated or if you switch policies, it's your responsibility to let us know this prior to undergoing further services. It is possible that at some point your insurance company may request a copy of your file in order to determine whether your treatment is for a non-covered or pre-existing condition. This is a matter over which we have no control; we cannot withhold or alter records. There is a nominal handling fee for making those copies. The medical personnel in our office, including Dr. Peress, are devoted exclusively to your medical care. Please direct all matters relating to fees, billing, and insurance only to the business office. I understand and agree to all of the above. I hereby authorize the release of medical information to my insurance company and authorize payment of medical benefits to Dr. Peress and/or BocaFertility.

Payment is due at the time of service. If you wish to know the fee for any service in advance of scheduling, please feel free to ask the receptionist. By typing your initial in the box below you agree to accept the terms of our fees policies.

 

*Your Initials:  

 

Dear Patient, on behalf of Dr. Peress and the staff of BocaFertility, we would like to welcome you and to answer some of the questions you may have about us.

 

What is Boca Fertility?

BocaFertility is a private medical practice dedicated to the specialty of reproductive endocrinology. A reproductive endocrinologist is the most highly trained infertility specialist, having completed intensive study in infertility, female hormonal problems, and reproductive surgery.

 

What type of tests and treatment will I undergo?

This will depend on how much previous infertility testing you have undergone and the nature of your specific problem. If you have not yet had a basic infertility workup, some blood tests and diagnostic procedures will be recommended first in order to try to find the cause of your inability to conceive (or carry a pregnancy). Any testing you have already done will generally not be repeated. Your treatment plan will be devised by Dr. Peress based on your diagnosis and treatment history. It may include medication, surgery, artificial insemination, and/or in vitro fertilization.

 

Will you need my previous records?

Yes, these will be very important at the time of your initial visit. Please bring them with you or have them sent to us prior to the visit. Feel free to call us to make sure they have arrived. Please be sure that the records include (if applicable): the operative report, surgical videotape, and the tubal x-ray films (available from the hospital).

 

What are your hours?

Appointments are scheduled from 8:00 AM until 4:30 PM. Certain types of visits do need to be scheduled at specific times of the day, however. Weekend appointments are available for procedures which require special timing. Our telephones are answered from 8:00 AM until 4:30 PM.

 

How long will I spend at each visit?

You should expect to be in our office approximately an hour and-a-half on your initial visit. Subsequent appointments will last one-quarter to one-half an hour, except for special procedures. We attempt to keep your waiting room time to a minimum. We do ask you understanding if some unforeseen circumstance occasionally causes a delay.

 

How will my care be coordinated with my other doctors?

While you are undergoing treatment at BocaFertility, you will continue to be a patient of your regular OB/GYN. You should schedule your annual pap smear with him/her and contact his/her office for any gynecological problems not related to your infertility treatment. If you become pregnant, Dr. Peress will provide your early prenatal care, and then refer you back to your OB/GYN.

 

If you are being treated by another doctor for an unrelated medical condition, please inform Dr. Peress. Please also let the other doctor know that you are attempting pregnancy, and ask whether any medications he/she has prescribed for you are safe to take at this time.

 

If your husband is undergoing medical treatment, he may wish to ask his doctor whether the medication prescribed to him will affect his fertility.

 

What type of payment is accepted?

We ask that payment be made at the time of service, and we accept checks, MasterCard, Visa, and Discover. If you plan to pay by cash, please note that we do not keep any cash in our office, and therefore cannot make change. (We can credit your account for the difference or mail you a check.)

 

Dr. Peress is a participating provider in many PPO and HMO plans. If you are insured with a plan to which we belong, you will be responsible for your co-payment, deductible, and any non-covered services at the time of the visit.

 

We hope this has answered most of your questions. Please feel free to call or office if you have any additional inquiries! Throughout your treatment at BocaFertility, please feel free to discuss with us any concerns you may have. We will do our utmost to answer your questions and solve any problems, should they arise. We look forward to meeting you and offer you our best wishes for an early success!

Sincerely,

The Staff at Boca Fertility